AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (141)

•Diagnostic Errors (156)

•Identification Errors (109)

•Discontinuities, Gaps, and Hand-Off Problems (367)

•Fatigue and Sleep Deprivation (83)

•Medication Safety (915)

•Medical Complications (377)

•Nonsurgical Procedural Complications (93)

•Surgical Complications (642)

•Transfusion Complications (13)

•Psychological and Social Complications (126)

Origin/Sponsor

•Africa (3)

•Asia (32)

•Australia and New Zealand (73)

•Central and South America (6)

•Europe (335)

•North America (2817)

Resource Types

•Clinical Guideline (9)

•Journal Article (2437)

•Legislation/Regulation (57)

•Meeting/Conference (22)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (288)

•Press Release/Announcement (23)

•Special or Theme Issue (63)

•Tools/Toolkit (49)

•Web Resource (100)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (738)

•Active Errors (553)

•Latent Errors (201)

•Near Miss (60)

Approach to Improving Safety

•Quality Improvement Strategies (796)

•Legal and Policy Approaches (274)

•Error Reporting and Analysis (801)

•Communication Improvement (908)

•Human Factors Engineering (478)

•Teamwork (406)

•Specialization of Care (222)

•Logistical Approaches (224)

•Culture of Safety (406)

•Technologic Approaches (522)

•Education and Training (668)

Clinical Areas

•Allied Health Services (9)

Target Audience
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Health Care Providers

•Allied Health Professionals (4)

•Clinical Technologists (21)

Setting of Care

•Psychiatric Facilities (12)

•Residential Facilities (56)

•Ambulatory Care (293)

•Outpatient Surgery (46)

•Patient Transport (29)

1 - 20 of 3302

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STUDY

Impact of preoperative briefings on operating room delays.

Nundy S, Mukherjee A, Sexton JB, et al. Arch Surg. 2008;143:1068-1072.

STUDY

Interruptions and miscommunications in surgery: an observational study.

Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.

COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

STUDY

Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery.

Henrickson SE, Wadhera RK, ElBardissi AW, Wiegmann DA, Sundt TM. J Am Coll Surg. 2009;208:1115-1123.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

STUDY

Improving operating room safety.

Hurlbert SN, Garrett J. Patient Saf Surg. 2009;3:25.

COMMENTARY

Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.

Erickson TB, Kirkpatrick DH, DeFrancesco MS, Lawrence HC III. Obstet Gynecol. 2010;115:147-151.

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

STUDY

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.

STUDY

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. BMJ Qual Saf. 2011;20:102-107.

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

STUDY

Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients.

Privette AR, Shackford SR, Osler T, Ratliff J, Sartorelli K, Hebert JC. Ann Surg. 2009;250:316-321.

COMMENTARY

The Inside of a Time Out

Feldman DL. AHRQ WebM&M [serial online]. May 2008.

COMMENTARY

Sleep deprivation, elective surgical procedures, and informed consent.

Nurok M, Czeisler CA, Lehmann LS. N Engl J Med. 2010;363:2577-2579.

REVIEW

Detecting adverse events in dermatologic surgery.

Pinney D, Pearce DJ, Feldman SR. Dermatol Surg. 2010;36:8-14.

STUDY

Can aviation-based team training elicit sustainable behavioral change?

Sax HC, Browne P, Mayewski RJ, et al. Arch Surg. 2009;144:1133-1137.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

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